Contact Us (P) 888-467-3330 ext. 102
(F) 888-453-5755

Quick Quote

General Information


Complete Legal Name

Street Address
Phone (required)
Email (required)
Years in business

Package Insurance

Name of current insurance company
Expiration date
Building Coverage
Contents Coverage
Square footage of space you occupy
Square footage of your building
Year built  
If built before 1990 last updated
# of stories
Sprinkler system in building YesNo Central station alarm YesNo
Refrigeration maintenance agreement YesNo Value of unattached sign
Does your store do any cooking? YesNo If yes, is there an ansul system YesNo
Total estimated annual sales
Total sales of privately labeled/relabeled sales
Total value of point of sale system $ Total value of product stored in refrigeration $
Liquor Sales $ Is alcohol served on premises? YesNo
Is there a restaurant located in the entire building you occupy? YesNo
Are there residential apartments located in your building? YesNo
Are you involved in any other type of business? YesNo

Building Construction


Umbrella YesNo Limit$

Workers Comp

Name of current insurance company Expiration date
Cannot Quote WC Without the FEIN
Experince Mod Exec. officers included YesNo
Class / Code
Store / 8017 $
Store / 8006 $
Clerical / 8810 $
Other $


Number of property and liability claims
in last 5 years
Amount $
Number of workers comp claims
in last 5 years
Amount $
Completed by: Date
If you have any questions please contact Mark Kapatoes
Phone - 203-507-6068
Email -